My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down.
So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

There have been some interesting responses to this month’s posts. It’s encouraged me to think about perhaps resuming for a month in the autumn and then again in March 2015. It’s been especially interesting over the last week to gauge people’s response to my attempts to challenge the gloom being spread about the pressure on the NHS by too many of NHS leaders.

In this last post for the moment, I want to try and think through how the current political leadership – that which might be in charge of the NHS in the period after the May 2015 election – can help make the necessary transformation.

And in thinking through the possibilities I want to introduce the fact that from tomorrow there is a new CEO of NHS England – Simon Stevens. Between 2001 and 2004 he was a close colleague of mine, and is a friend, so I wish him well. But too much expectation is being placed on the ability of one person to make everything happen. He can and will achieve a great deal – but no-one can do this on their own.

When Pete Seeger died in January one of the many brilliant sayings that were attributed to him was, “Be wary of great leaders and hope that there are many many small leaders”. To succeed Simon will need many many small leaders.

And I don’t know about you but it seemed to me that there was something really odd in what his predecessor David Nicholson said in an interview last week. He said he would give NHS England “5 out of 10”. Given that he ran the transition body that set up the organisation, was responsible for the hubristic change of name to NHS England, and then ran it throughout its life one wonders, if the organisation is not very good, just why is that?

But the rest of this post concerns the interaction between political leadership and the NHS.

There is near universal agreement between the two major political parties who will either form the next Government alone or will form the larger part of any coalition. (Incidentally we don’t yet have UKIP’s NHS policy but I’m sure that if you visit any Home Counties’ saloon bar on a Sunday lunchtime you will hear it there first).

Both the Conservative and Labour parties agree that:-

There will be standstill funding. Money won’t go up, but it won’t go down either. (But by 2020, even if the money is still the same for the NHS, most other areas of public expenditure will go down so the proportion of public expenditure being spent on the NHS will rise considerably).

There will be no new structural reorganisation. (phew!)

There will be many more older people with co-morbidities who will need different and better care than they are getting at the moment.

There need to be many fewer emergency admissions.

There needs to be a rapid development of integrated health and social care.

This new model of care will have a radical impact upon the existing models of health and social care.

They also know that these changes need to happen quickly, need to happen across the whole of England, and that given the rise in demand they will need to reduce the amount of money spent on each patient.

Now of course we don’t know what the manifestos will bring but at the moment, given the pledge that there will be no more top down reorganisations, the levers that are available to bring about these radical changes are limited to what they have to hand at the moment.

The problem with this is that none of the political parties really agree with the current organisation of the NHS and the existing levers for change and so none are at all happy with what they have to hand.

Let’s start with the Conservatives. We know that the current Conservative Secretary of State Jeremy Hunt voted for the Health and Social Care Act on many occasions and supported the reforms in Cabinet. He was lucky enough to be in the job of Secretary of State when all the reforms he had consistently supported came into effect. Few politicians enjoy such a luxury.

But, as we know, a curious thing happened during the time between the passage of the Bill and his having the opportunity to enact the reforms.

Over the intervening year he came to disagree with the central idea of his legislation, that the NHS should be run by a series of arm’s length bodies – separated from the Secretary of State.

Instead of following the core principle of the reforms – to liberate the NHS from Whitehall – he instead runs the NHS from his office (in, er, Whitehall). Most of the time he ignores the legislation he supported (and, it might be said, much of a decade of earlier legislation.)

You would have to spend a long time searching through his speeches to find any reference to the changes that he wants being made by the actions of the 211 clinical commissioning groups that his legislation established.

Let’s look at an example of what he might do if he believed in the legislation for which he voted.

A few weeks ago the Times uncovered the fact that over 150,000 older patients are moved around our hospitals in the middle of the night. If he used the powers in the legislation that he voted for, he would read the Times and think hard about changing next year’s mandate to NHS England to cover this issue. He would in turn talk about how CCGs should commission care from hospitals that did not involve such nocturnal movement of older patients.

Instead the anxiety that the Times headline immediately raises in him leads him to try and ensure the NHS acts differently. Since he won’t do that by using the levers his reforms gave him, he has to resort to shouting at the NHS as loudly as possible.

And this will be the problem for the NHS if the Conservatives are in charge of making the changes to bring about integrated care from 2015-2020. Since they don’t believe in the purchaser/provider split that is the keystone of their legislation, they have no other levers available to bring about these radical changes.

What they have instead is the traditional activity of shouting at the NHS to “just do it!”. Since the NHS knows that if, a week later, there is bad publicity coming from trying to create integrated care at pace, it is likely to be shouted at to do the reverse, there is little likelihood of reform taking place at the scale and pace that is necessary.

Labour of course has yet to outline the detail of its policy. But in the last month the leader of the Labour Party and the Secretary of State have both agreed that there will be no top down reorganisation of the NHS. That good news means that the levers for change contained in the current system are the only ones that will be available to a Labour Government in May 2015.

Which in turn means that commissioning at a national and local level will be the levers to bring about the move towards the integrated care outlined above. Yet the Shadow Secretary of State has made clear that the last thing he want commissioners to have at their disposal is competition. He wants to grant the existing NHS suppliers a monopoly of what health care is supplied and who supplies it.

He will therefore be asking the NHS to carry out very different integrated health and care but taking away any ability that commissioners have to challenge the monopoly of existing institutions. This reduces commissioning to an allocation mechanism with commissioners simply handing out money to existing NHS providers.

If this were to remain Labour Party policy after the next election, they too will have no levers to bring about integrated care except for the time honoured method of shouting at the NHS.

So, a year away from the next election, this is the problem.

We have unanimity about where the 2 main political parties think they want the NHS to get to.

We have agreement that there will not be a reorganisation to give the Secretary of State new levers

We have agreement that the current levers aren’t one they want to use.

They have no way of getting the NHS to move to where they want it to go.

All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to discuss the money.

The money is one of the main arguments that feels overwhelming. This is partly because more and more people in the NHS believe that there won’t be more and more money and that’s a bit overwhelming.

For 60 years we have all been working in a service where we have been getting a larger slice of a bigger cake. The GDP has been growing and the proportion of that GDP that has been going into the NHS has also been growing. Even in difficult times, taken over a five year period, the amount of money has gone up and up.

For the last few years it has not been going up. But many people believed that eventually normal service would be resumed and money would start going up again. Only over the last few months have more and more people begun to recognise that if we are very lucky between now and 2020, it won’t go down.

(Of course there are still some whose wishful thinking overcomes their judgment. But I hope for them that the passing of the budget last week – without a few billion extra pounds for the NHS – marked the end of that hope. The moment of maximum political pressure is the budget 14 months before an election. If the money is not found then why would it be found in the first four years of a new Parliament? No. What we have is what we will get)

As more people realise this they begin to talk about the “Graph of Doom”. This shows demand increasing every year while money stays the same. The doom comes from the growing gap – that gets bigger every year.

This gap is based upon the expectation that we will continue to do what we have done before. If demand has gone up by 20% by 2020 the expectation is that, given we will treat these new sick people in the same way as we have treated sick people before, we will need 20% more money to do it.

We heard this logic last week when the RCGP said that to meet the new demand there would need to be 10,000 extra GPs. As reported the story contained the rather odd claim that GPs might become extinct.

(That’s a very strange word to use about the future of a bit of the medical profession. Is there no little bell that goes off in people’s heads when they make these claims?)

It’s true that GPs are under great pressure from rising demand, and what some of them are doing as I discussed on Wednesday in my blog about technology, is changing the nature of their consultations with patients to utilise their time and skills in different ways.

The NHS and social care will not be treating that extra 20% of demand in the same way that we treat them now. If they (and we) are lucky we will be providing a much better service of coordinated care with much less use of emergency beds for fewer exacerbations.

The NHS is not full of people who in five years’ time will have to do what they did five years ago.

It’s not full of people who have to deliver exactly the same service that they did five years ago in five years from now.

But it is full of people, at least those over 30, who have been used to working in a service where the money goes up all the time.

What we need to do is to use the inventiveness that has been there in the past to incorporate new forms of treatment to the service for better value for money.

One of the reasons why people are not doing that is that their leadership has been talking in such gloomy doomy ways about everything – including the money.

What we need from the new leadership of the NHS is some concerted hope for the future which sees all these difficulties that have been described as “overwhelming us” as issues that provide opportunities for development.

With a bit of good leadership we won’t be overwhelmed, but will use these pressures to grow.

My last post of this month long return to the blogosphere will be about the prospects of political leadership facing these changes.

All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to discuss what is seen as the problem of rising expectations.

I started working in public services, in London local government, in 1984. From the start, and continuously over the last 13 years of working in the NHS, I have heard leading public servants complain about the rising expectations of the public.

The argument is straightforward. If the public expect more, we can’t deliver it and it makes out job harder. So ‘rising public expectations’ over the last 30 years have consistently made our job harder.

In its own terms you know what people mean when they say this. If the public don’t complain and fit in with how we organise ourselves, (for example by not getting sick between Friday afternoon and Monday morning when we aren’t there) then the work of a health service is a lot easier.

If people are prepared to travel a few miles to what we refer to as an “outpatient clinic” (but which is in fact inside the hospital so should be called an “in-patient clinic”) and turn up with a crowd of other people at 0900 to be seen at 1215 then our organisational ability will likely meet their low expectations.

But over the last 30 years more and more people have found that in the rest of their lives they can make an appointment with, say, their hairdresser – near their home, at a set time and will probably receive a text reminder beforehand. And on nearly every occasion there will be someone ready to cut your hair at the appointed place and time.

Given that a hairdresser can organise this, the problem for the NHS is that now they now expect it to do the same.

A coda here about class.

Amongst the top 10% of the population I am not sure that expectations of public services have increased in the last 30 years. In the mid-1980s the top 10% expected to get respect, courtesy and convenience for all the services they used – public and private. And when they didn’t get it from the NHS they made a fuss.

For them expectations have always been high.

No the problem of rising expectations for the NHS is caused by the fact that ordinary people now have greater expectations of it than they had 30 years ago. From amongst a class of people who were once simply grateful more and more people have emerged with higher expectations.

This means that more and more people expect services to be organised around their lives – and not around the needs of the organisation .The main problem is not the rising expectations, the problem is that we now need to confront the way in which many of our organisations work for their own convenience.

And it’s true that people are more informed and inquiring. They are demanding a greater say. Ordinary people are getting a taste for greater power and control in their lives.

One of the main political points I want to make is that the very existence of mass public services raises expectations.

Expectations of what the NHS would be had been raised, from its very creation, by the public’s experience of World War II. That generation expected more from life and from Government. (It was just as well that that generation also had the courage to hold high expectations about beating the Nazis).

The point of mass secondary schooling was to raise the next couple of generations to want to attend university.

If people involved in a large scale public service complain that the public want more then they don’t “get” the movement of history of which created their service in the first place.

Now there is apparently a problem because too many people are getting too much information about health and health care.

In the past people would talk to their immediate family before a visit to their GP. Now more and more will consult the internet and walk in to see their GP with printouts. In the past they would come in with bits and pieces of knowledge from their parents and grandparents, now they come in with bits and pieces of knowledge from the World Wide Web.

Of course this knowledge is not ‘correct’ but it’s there – and it’s there to be referred to when the patient has had their consultation. The doctor can’t say “don’t go on the internet” in much the same way as in the past he couldn’t say “don’t talk to your grandmother”.

So rising public expectation is seen as a problem across the whole service, from consulting room to boardroom.

Yet in other industries and services, there are attempts to raise expectations and organise to meet them.

In the hotel industry for example one can imagine that a hotel manager may feel that Trip Advisor makes their life a lot harder. I can imagine them moaning to themselves about the latest complaint on the website. But what I can’t imagine them doing is talking to their staff in their morning meeting and complaining about rising public expectations of the hotel.

Nor can I imagine a similar discussion taking place in the boardroom of the hotel chain.

In the hotel industry, and in most other services, the role of the leader of an organisation is to use those higher expectations to drive improvement. The problem for leaders in other industries is constructing a service when the public doesn’t know or demand what it wants.

The same is true for the NHS. The problem for the health service is caused by people putting up with fragmented services that don’t help their recovery.

To create a really successful health service we need, both in the consulting room and among the public, much more active engagement and we need to use that activity and demand for better health and healthcare as an asset.

This week I gave a talk at a mental health trust about these issues. I just caught the end of a patient’s story when she said that the pivotal moment for her had been when a member of staff had said to her that one day she, the patient, would get a job and go back to work. At that moment it was not imaginable, but slowly that hope of a better outcome raised her own expectation. She was then able to use that raised expectation to recover.

Recovery in mental and physical health is assisted by the raised expectation of recovery. Good medicine works with not against that expectation.

All this week I am trying to unpick the five major arguments being made about the overwhelming pressures that challenge the NHS. I am trying to uncover why the way in which these arguments are made is, rather than unlocking and forcing change, making that necessary radical change more difficult.

My overarching point is that it is the posing of these arguments as a set of challenges that are in fact overwhelming the NHS. What I am trying to is to demonstrate that each challenge presents opportunities for the NHS to adapt rather than being overwhelmed.

Today I want to look at the nature of technology.

In our everyday lives technology enables. Sometimes it frustrates but mostly it makes our lives a lot easier. Modern communication is rarely a burden and mainly a boon. In our world it doesn’t feel like an overwhelming challenge.

The challenge of new technology for the NHS lies in the enormous and recognised gap between what the NHS knows it is achieving through technology – and what it knows it could. Most people, whether they be a district nurse in a patients’ home, a GP trying to find out which drugs were prescribed to their patient in hospital, or a patient just trying to find out what is going on, know that their experience of the NHS is not as “technology enabled” as it could be.

Each of them, and others beside, recognise that simple and cheap elements of new technology could transform the ways in which things work – and how they are looked after.

Indeed some of this is not new technology at all, but is old technology used to its full potential. A GP friend of mine always used to say that if doctors ever recognised that the telephone was a two-way instrument – that could be used to talk to patients as well as having them call you, the consultation process could be transformed.

And within that observation lies an important truth. New technology only really works if it enables something that the NHS already wants to do. Too often the NHS has tried to use technology as a change agent in its own right. When that happens the current way of working – the current culture – maintains its old way of working and the new technology simply bounces off it.

Its lies like a heap of junk in the corner of the room.

So the battle for modernity in the NHS needs to be won by using technology as a small part of change, rather than as its main driver.

One example would be changing the nature of the GP/patient consultation. The technology supporting telephone consultations has been around for a long while. The technology for email consultation for not so long, but few people would still refer to email as new technology.

Yet it is only in the last couple of years that the GP practice with multi-channel forms of consultation has developed with any scale. ‘Getting to see’ the doctor has become less significant than ‘talking to the doctor’. This hasn’t abolished the face to face consultation, but it has placed it in a multi-channel set of contacts.

This has not been caused by the invention of the telephone and email. It is a consequence of some GPs recognising that they have to change their core practices if they are to serve the best interests of their patients and then using ‘new’ technology to facilitate the change. Once the decision to change has been made really new technology can transform this multi-channel relationship with patients.

In the future we will see this as a significant change in one of the core relationships of medicine. Given that we know that the main site of health care is the patient’s own home, interacting with the patient there during consultations will become ever more important.

If we succeed in making the home technologically enabled – so that it can provide a place of safety for high acuity cases – then the ‘burdens’ of both aging and non-communicable diseases (discussed over the last two days) will be transformed.

The potential here is transformative. It provides us with a real chance to address the disparity between the services that are provided – with their over-emphasis on hospital-based care – and those that are needed – for more care in the community and at home. The opportunity is to harness technology – from big data, through patient-owned health records, to mobile health applications – to help make that transition.

And before anyone points out that the use of modern forms of communication is differentially spread around the population, this is of course true. But the relationships formed by new forms of communications are surprising and can be developed by the NHS. Many people much older than me have benefited from using Skype as they keep in contact with their family across the world. Grannies rent or buy new TVs so they can have big pictures of their grandchildren beamed in from New Zealand.

What we know about this technology is that the public will only use it if there is a point to using it. Grandchildren provide such a point.

I would suggest that the better management of health – staying out of hospital – will provide a similar powerful motivation.

New technology will be an enabler in developing the public’s motivation for better self-care. But it will not make that happen. That will need a better understanding by the NHS of what motivates people to better self-manage their own lives.

This is the second of five posts exploring the way in which discussions about pressures on the NHS are being framed by its recent leadership and current commentators.

Yesterday I challenged the widespread assumption that the increase of the proportion of elderly in the population would from now onwards be seen as an overwhelming burden for the NHS whereas other industries see older people as possessing assets – assets that would be much more useful for a health service to work with.

I argued that characterising such problems as overwhelming does not bring about change but makes the NHS ‘hunker down’ under the status quo.

Today the second of my five posts focusses on the way we frame the argument about the fact that, in England, disease in the 21st century is different from that of the 20th.

Commentators, including myself, have said that the radical change in the nature of disease is a very big challenge for the NHS. The diseases that the NHS took on when it was founded in the last century have now been if not conquered certainly tamed and this century’s disease battle is very very different.

Health systems now have to tackle non-communicable or chronic disease.

As with the increase in the number of old people this issue is often presented using drowning metaphors – a wave, a flood or a tsunami of need is being talked of. The same enormous increase in figures used in regard to the numbers of the elderly are deployed again.

The first thing to say about this change in the nature of the diseases that the NHS has to deal with is that it is not a future thing, it is already here. Given that even today about two thirds of the NHS budget is spent on chronic diseases we must recognise that the problem has already arrived.

The fact that statistics for nearly every non-communicable disease point to a dramatic rise over the next few decades seem to ramp up the size of the problem to another one that is overwhelming.

Firstly it’s important to see that some of this is a problem of success. All of these conditions are more prevalent with age. The older the population, the more likely it will suffer with long term conditions. The fact that we are living a lot longer is partly due to the NHS, so the fact there are more people with non-communicable diseases is also partly due to its success.

In the pretty nigh unending battle between disease and human endeavour, notch one up to us in ensuring people are living longer.

Let’s take the specific of heart disease.

When I grew up in the 1950s the expectation was that when someone had a heart attack they either died or they quickly had a second heart attack – and then died. That has changed dramatically. Over the past 20 years survival rates have increased and now many more people survive heart attacks. We are now much much better at stopping the attack from destroying the heart and much better at stopping the second attack. We are also much better at diagnosing a ‘weak heart’ before an attack.

All of this means that there are now many more people with ‘heart problems’ than previously. It’s difficult to see this as anything but success.

The same is true of cancer. Go to the Macmillan’s website now and you will read a lot about survivorship as a major issue for people with cancer. Again in the battle between disease and humankind I can’t but see this as another great success. Much more to do, but so many more people surviving is a good thing.

So why is the changed nature of disease with which the NHS deals with such a problem? The main issue is caused by that word ‘change’. The NHS is shaped to do one thing and it now has to do another. It finds that change hard, but such a change does not have to be overwhelming.

The main reason it is described in this way is that the nature of the change the NHS needs to go through involves how 15 million people with long term conditions need to maintain their health. This, as a task, seems beyond the NHS – and in a literal sense they are right, it is.

The only way this new form of illness can be tackled by a health service is to recognise the importance of the people themselves in managing conditions. On its own the task lies beyond the boundaries of any health service. The service needs to find different ways of working to include and involve those people in much better maintenance of their condition.

What patients do to manage their condition – their lifestyle, diet and exercise – is as important as everything clinicians do.

A successful healthcare service needs to enhance the nation’s capacity to look after itself when it is ill.

Of course a really successful health service needs to enhance the nation’s capacity to look after itself before it is ill.

The danger is that the NHS sees itself as being overwhelmed by non-communicable diseases because it has to change to treat patients differently. They need to be seen not as passive recipients of care in a system that denies them both power and responsibility but instead as an integral part of a system that empowers them to take greater charge and more responsibility for their own health.

A model of health care that is controlling finds the necessity of this change overwhelming.

But in reality it is an opportunity is to bring patients inside the decision-making tent. An opportunity to let go of all that responsibility and let patients share the dilemmas clinicians and managers face – rather than keeping them outside.

This is only overwhelming if the NHS cannot let go of this power. What will be overwhelmed is a particular model of health care – not health care itself.

One of the main purposes of this blog is to question some of the established orthodoxies of the NHS and how we think about it. By definition that means that I raise questions all the time about how the NHS thinks about the main issues it faces.

For the last five posts during this month of my return to the fray I want to develop a different set of arguments. These will question why so many leaders and commentators in the NHS seem to need to passionately portray the organisation as being mired deep in a many faceted crisis.

There is constant talk about ‘the graph of doom’ which has demography rising and resources flat lining.

I want to explore the nature of the psychological need that is being met by this constant return to viewing the world in this way.

Because, from the outside, all this talk of doom seems to make the job of actually achieving anything very hard indeed.

One way of looking at this is that if there are…

too many old people

too many sick people (who are also apparently the wrong sort of sick),

too many changes in technology

sky-high rising public expectations and

no new money

…then don’t all of these external factors create a set of drivers which argue relentlessly for the necessity of radical change?

One would think so. But then in the real world where these arguments are being made by and large radical changes of scale are not being made.

So I think we need to think of another purpose that this way of looking at things serves. If all of these external factors are coming together to create pressure for change isn’t it also the case that change on this scale can’t be achieved? So, the argument goes, this is all so overwhelming that nothing can be achieved – so let’s carry on much as we are already.

So the paradox of this week’s posts is that what should be powerful arguments leading to change have in fact become OVERWHELMING arguments resulting in people not knowing where to turn.

I am grateful to my old boss Alan Milburn for showing me how these arguments need to be turned on their head. A few weeks ago at the Guy’s and St Thomas’ Charity he gave a lecture on how all of this overpowering doom could be a set of opportunities for the service potentially leading to very different leadership activities.

Because, as with so many things, this is all about leadership. The framing of the argument is a matter for the leadership of the system. And at the moment that argument is being framed to be so overwhelming that everybody is being frightened back to the status quo.

This week I want to spend a day on each of the five areas which have been portrayed as overwhelming challenges and see what possibilities they provide the NHS.

Demography

The nature of disease

The nature of technology

Public expectations

The money

On demography I need declare an important interest. I am 65 – the same age as the NHS – and therefore part of the age group and generation that are being seen as the burden that will destroy it.

Personally I don’t quite see myself as a burden but I sort of get the point.

However, my generation – colloquially referred to as the “baby boomers” – has, until now, more often been seen as a generation causing problems because of too much activity – not too much passivity.

We were – just – young mods and rockers (in my case a failed rocker as I never mastered riding a motorbike); we developed and sustained several parts of pop culture; we were the first major wave of student unrest; we were an early part of the property boom; we rode a tide of divorces and changed jobs far more often than previous generations.

All of this seems very active. (For our parents, much too active.)

Apparently now that we are entering retirement we are going – for the first time in our lives – to become a passive burden, rack up several co-morbidities and spend the last 30 years of our lives bothering doctors.

Old people are not just often referred to as a ‘burden’ but we also seem to feature in a lot of ‘drowning analogies’. There is, and will be, a flood of demand which will lead to the NHS drowning under it. All of this becomes a tsunami of need.

One of the statistics used to make this case is that by 2030 a third of the population will be elderly. This is assumed to clinch the whole argument since a problem that big must be insuperable. Personally I would be 82 and be part of this flood by being ill, and passive.

I think it’s certain many of us will be ill. My aches and pains will develop into arthritis and I am pretty sure that my blood pressure will be too high. Almost certainly I will also have another morbidity.

So it’s true that there will be more of us and that many of us will be ill in complex ways.

But will we be ill in the same way as today’s 82 year olds?

When I read the Saturday and Sunday supplements many of them treat me as a very active consumer for the rest of my life. I read them as appeals to me and older generations to become ever more active. There are a whole host of organisations that are looking to me to be very active indeed when I am in my 80s.

Private sector organisations assume I will be very active.

The NHS assumes I will be very passive.

Voluntary sector organisations see me as active.

The NHS sees me as passive.

The NHS assumes that its burden (and the problem of their increasing activity) is caused in part by my passivity.

But what will be the characteristics of my activity that the NHS, if it understood me in that way, could work with?

How might my GP be encouraged to view the next 30 years of my life as a set of assets with which the NHS can work?

One of those assets would be my wish for my home to be the established and clear locus of health care. I do not want care closer to home. I want care at home.

Our care will be centred on our experience of our own homes and not designed for the convenience of the organisations that will deliver it. My generation will expect much more high acuity care in the comfort of our own homes.

This will be a challenge to the current way of working. The new generation of the old will not tolerate a system of care that tells us what to do. We will want to tell it what to do.

But for the NHS this is also a very considerable opportunity. It will require a shift in the way in which the NHS delivers care but that shift would be based upon a recognition of our capacity to play a much bigger and active role in our own health care.

The opportunity is to re-fashion care so that it is aligned with the mind-set of this century rather than the last.

I know it doesn’t feel like it in 2014, but the dynamics of disease will move the NHS into an era which will either fully utilise patients and their carer’s capacity to better self-manage their conditions – or collapse.

The old model of healthcare will not be able to muster sufficient resources to cope with the new model of disease.

Moving from here to there will be difficult, with many fits and starts, but patients and their organisations will be the main force that will drive this change.

That’s why yesterday I posted that too much of what is at the moment called “integrated care” is simply shuffling existing services around and hoping they will fit.

They don’t.

Given the multiple morbidity of many patients it will take much more than this to create care that is properly coordinated.

Above all it will need investment in the assets that patients, their carers, families and communities have to better manage their conditions.

This process starts with a very difficult set of changes from inside the existing model of care.

At the moment many medical staff, seeing a list of sick people – some of them very sick – fairly inevitably see their patients, carers, family and communities as a set of deficits. Patients are seen as lacking average blood pressure, good breathing, the ability to be active in the world, the ability to manage their condition themselves etc. etc. Patient after patient comes in expecting some external help from the doctors and the nurse.

This experience makes it fairly likely that the tenth person who comes into the clinic will be seen as a set of needs – and not as having any assets.

Which of course becomes a self-fulfilling prophecy. The NHS sees no assets amongst the patients and the patients therefore don’t feel, when they come into contact with the NHS, that they have any.

But if we continue in this way, treating patients as if they are nothing but deficits, the health service collapses under the weight of demand from co-morbidities and an insufficient supply of medical staff kit and drugs.

Finding out what assets people have is not a straightforward process. Different people have very different assets.

Many people have family and friends who can do much more than take a prescription to a chemist. But to do more they need some investment of time and effort from the NHS. Helping people to play a bigger role in helping other people first requires the recognition that there is something there to work with and then some time and effort to help them know how to improve the patient’s capacity to self-manage.

But others – the very old and the vulnerable – may be very isolated and have lost all their organic relationships with family and friends. Here the NHS needs to find ways in which local voluntary and community groups can stand in.

Last autumn the Red Cross fundraising campaign had a picture of an isolated older lady at home in this country. This, not the health outcomes from an earthquake in another country, was ‘the crisis’ that the Red Cross was pledged to help to solve. For some years now the Red Cross have been training volunteers to spend time with isolated patients.

Of course they are not alone in this.

Organising someone to visit an otherwise isolated person is not something that a busy GP can take on board themselves. It may only rarely make sense for a doctor to find out about all the voluntary groups in their area, but it always makes sense for them to have someone who knows to whom they can refer the patient. This practice of social prescribing is gaining recognition within the NHS.

If the increase in the number of people with several long term conditions is the disease burden with which our health and social care service needs to cope, then my point is that the only way that this can be done successfully is with the very active management of patients themselves.

Changing health and social care to achieve this will not be easy.

Last year, before I suspended blogging, I posted about the work that I and others had carried out with NESTA. There are several publications on their website that flesh out how investing in better self-management can work for the NHS.

Across various parts of social care and the NHS the last year has seen a great deal of planning to create what the NHS and local Government likes to call ‘integrated care’. (I commented yesterday on how providers of care like to call it this whilst patients like to talk about ‘co-ordination’).

Across the country, there are regular meetings where teams of people are sitting down and looking at their existing services and trying to stitch them together into a different pattern.

Over a year ago I tried to understand why this was so very difficult. Staff wanted to do it; patient’s carers and the public wanted to do it; resources were demanding it. But, meeting after meeting, it kept on not happening.

My answer to this conundrum is that we underestimate the passion with which staff and services have developed their fragmented bit of the whole. More and more people come to work in health and social care with greater and greater specialisation in their work. Most careers have been developed not around better coordinated whole person care but around greater specialisation.

Two weeks ago, tucked away in John Oldham’s report on Whole Person Care was the recognition that the way in which merit awards were granted to the medical profession not only encouraged but practically enforced body part care rather than whole person care.

In the field of social work, despite several decades of argument for generic social work, specialisation is how you get ahead.

Of course staff don’t come to work with the aim of fragmenting a person’s care. They come to work with the experience of working only with diabetes; only with residential homes for residents with dementia, or only with depression. The constant in their work is the specific illness – the variable is the human being.

And it is not wrong to describe staff as ‘passionate’ about their specialisation. Hearing specialist consultants, nurses, or residential social care staff talk about their specialism is a moving experience. They really want to improve their skills but talk about more and more specialist activity.

This process has created passionate fragmentation.

And there are very many who believe that coordinated or integrated care will be created if we bring these fragmented services together. Rather like a jigsaw puzzle. So the job of the coordinated care officer is in some way to find the picture on the top of the box and fit all the pieces together.

It’s a compelling analogy – but it doesn’t work.

The jigsaw takes an existing picture – let’s call it “Whole Person Care in the Home”, cuts it into bits, and then jumbles those bits up. The coordinated care person a) knows that somewhere in all the bits there is a real coherent picture and b) that whilst it will take time and effort their job is to fit the bits together to make that picture – and given time and skill that is what they will achieve…

The problem for real coordinated care is that the fragmented services have NOT been created as a single picture and then fragmented. They have been created to only deal with bits. They have been created as fragmentations.

The big problem is that the part of the jigsaw for an 85 year old woman called “diabetes care” has not been created to fit neatly with the part called “dementia home care”, which in turn has not been created to fit with the part called “COPD care”.

They have not been created in a way that they will fit together.

The organisations that create them have made these services as “bits” in their own right.

So a really clever coordinated care worker can shake all the pieces out of the box for Mrs Patel’s whole person care and then find that the problem is that when they try and fit them together – they won’t. They were not made that way.

At best they might get a few that look a bit similar to form a line, but they will not form a picture of whole person care. And when you look at that line, there are holes in between through which patients fall, and duplications where they have to do the same thing over and over again.

To build a picture of whole person care you have to fundamentally change these fragmented services so that they might just fit together.

To achieve that coordinated care staff will need much much more power to transform existing service than they are normally granted.

It won’t surprise blog readers that I think that this greater power comes from patients and tomorrow I will describe how I think that might work.

Over the last year I have read more about integrated care than about any other health and social care topic, and even though I don’t read much more than 5% of what is published on the topic we are talking about what, in hard copy days, would have been called “forests of paper”. I am sure that in the digital world, there are several terabytes of disks filled with the stuff.

Over the next few days I want to make some comments about what has and has not been achieved in this area of health and social care in the past year, but first some comments about language.

Because so much has been written about integrated care, I want to say a few words about the language we use to describe the changes we want to bring about.

Quite rightly much is made in making the case for change for integrated care, of the bad patient experience created by the current model of fragmented care. Different specialists feeling they are the only doctor the patient sees; different nurses asking for the same back story to be outlined by the patient; different social care staff coming at different times to carry out un-coordinated care. At best it’s merely bewildering, at worse it has a bad effect on patient well-being.

Nearly every local case for change in integrated care talks about patient experience as a reason for change before resources are ever mentioned.

Given the recognised saliency of patient need in this set of changes, it’s a great pity that the language we use to describe what we are doing is still a language dominated by our task and not by language that patients can understand.

About a year ago NHS England commissioned National Voices to carry out a discussion with patients to find out how they and their carers describe the changes that we call “integrated care”.

The very fact that NHS England asked for this to be carried out was a recognition that the current method of description and explanation needed change. Commissioning the work was a good thing. But if you trawl through NHS England’s web site you will see that the changes are still referred to as “integrated care”. They paid for a patient centred piece of work to be carried out and then ignored it in their own practice.

After extensive discussion they found that the phrase that made sense to the public was “person-centred coordinated care”.

Integration is what the system needs to do.

Coordination is what the public need to experience.

The key wish for patients is that,

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me”

Contained in this sentence is the reason why language is so very important and why who is in charge of the language is such an issue of power over practice.

This sentence is reasonable. But it’s pretty obvious that it describes a way of developing care which puts patients in charge.

It starts off with I can plan my own care. Whilst this is ideologically what the NHS and social care claim to want, it fairly obviously implies that organisations that currently plan patient care around their needs would no longer be in charge.

With people who work together to understand me and my carer. Again ideologically it’s what everyone says they want – of course we work together to understand the patient and their carer! (Well no, that’s the problem isn’t it?)

Allow me control… Again the wish is that patients should have control, but the reality is that services are not organised around that concept.

…and bring together services to achieve the outcomes important to me. The clinching argument here is that the services would have to be organised around outcomes that are “important to me”.

So what National Voices have wisely done is to ask patients how services would be different if they were organised in their interests.

Unsurprisingly that resulted in not only a shift in language but a shift in the power that language describes.

And that’s the reason, a year later, we all go on talking about “integrated care” and not using the language that patients want to use to describe that change.

This is the rather sad conclusion. Even when the NHS genuinely wants to do something that is in the interests of patients and even when we explicitly find out how patients want to describe these changes we still can’t bring ourselves to put it into practice.

Our own language, our ability to talk to ourselves internally is much more important to us than our ability to communicate with patients.

And the reason for that is that we know once we start using the language of patients to describe what we should be doing, we will cede a lot of the power that we have over their lives to them.

Last Thursday the Secretary of State made an important announcement about NHS pay which was met with a lot of anger from NHS staff and their organisations. What is interesting is not just the announcement per se but the way that the Secretary of State chose to publicise it.

Those who felt that the way in which it was announced was deliberately designed to cause a row are almost certainly right.

Given that everyone in the NHS was either getting an increment or, if they were at the top of the scale with no more increments, getting a 1% pay rise this could have been delivered with a fanfare along the lines of “Good news everyone’s pay is going up!”. We could have had a few paragraphs promoting that message and then something about how it’s not as much as he would have liked because of the financial crisis.

But no, that is not what was said. Instead an acutely PR conscious Secretary of State decided that a good story about everyone getting a pay rise should be turned into the bad story that a consolidated pay rise of 1% would be impossible because it was unaffordable. He headlined the curbs rather than the pay rise,

“The Pay Review Body proposals suggest a pay rise that would risk reductions in front line staff that could lead to unsafe patient care” .

This will save £200 million a year. (Remember that figure)

So why spin a story saying this is bad news when it could be spun as good news?

Because we are but 12 months away from the start of the next general election campaign. A campaign that will, so far as the government is concerned, be fought on the economic competence of the Labour Party.

So what has NHS staff pay got to do with that?

If the Labour Party say that they will implement the pay review body recommendations, it will cost £200 million. They might seek to justify this in two ways that could play into the government’s plan to attack their economic competence.

First a naïve Labour front bencher might say that this is a punitive attack upon nurses and that after all it will only cost £200 million out of an NHS budget of £110 billion. A rounding error and not a big sum of money.

How might a government spokesperson respond to someone falling into trap number 1?

“Only an economically incompetent Labour Party would say that £200 million is a small sum of money. Any responsible political party would recognise that this represents the pay of an extra 4000 nurses, not a rounding error. This shows how once again the Labour Party cannot be trusted with your money.”

A second naïve approach would be for a Labour front bencher to say they would find the £200 million from inside the NHS.

How might our spokesperson respond to that?

“The Labour Party thinks it can simply conjure money out of thin air. It can’t. NHS money is being spent on patient care. What we need to know from the Labour Party is where it will cut NHS services to find this money? Until it does we believe this could be your local hospital.”

This Government will be looking for lots of small examples of how the economic arguments of the Labour Party don’t add up.

The politics of NHS pay is just another one.

Over the next year most announcements will need to be viewed through the lens of the election campaign in order to be understood.

But let’s return to the £200 million that Jeremy Hunt says is essential for front line services.

On the same day as the pay announcement another was made with far less fanfare. This was that government departments would make a much greater contribution to pensions for staff and that money would not be spent by the Treasury.

Next Wednesday, when George Osborne announces his budget, much will be made of a £1 billion infrastructure fund that the Treasury will pledge to spend on small infrastructure projects.

This £1 billion has been obtained by taking money from departments to pay for pensions that in the past were paid by the Treasury.

So Jeremy Hunt has agreed to give the Treasury £125 million a year that will now come out of his budget from 2015/6 onwards.

Surely, just as with the £200 million not being spent on pay rises, this £125 million can only be found by cutting front line services?

Odd that we’ve heard nothing about any cuts that might be needed to plug this £125 million gap.